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Circumcision: A Change of Policy

Posted on Jan 22, 2013 by Ailee Slater ()

To circumcise or not is a very personal question for new parents; it is a question with religious, medical, financial and social impacts. For many years, however, American health care institutions have given their opinions on whether or not circumcision is a good idea, and of those institutions, the American Academy of Pediatrics is one of the most important when it comes to making recommendations about the medical care of children.

In 1999, the American Academy of Pediatrics (AAP) released an official Circumcision Policy Statement. Following research by their appointed task force, the AAP concluded in this statement that although there were potential benefits of circumcising male infants, the data was not sufficient for the Academy to recommend routine neonatal circumcision. This lack of a recommendation did not sit well with the many medical practitioners who believe that circumcision is an important way to improve health among the male population. A 2008 report from the Journal of Infectious Diseases criticized this 1999 AAP study while calling attention to the role of circumcision in lowering the risk of HIV, and the publication Pediatrics released a commentary from Edgar J. Schoen, MD of Kaiser Permanente, accusing the AAP of ignoring blatant evidence about the benefits of circumcision.

Since 1999, many insurance companies have taken these recommendations from the AAP as a reason to deny coverage for neonatal circumcision. After all, if circumcision is not a medical necessity, why should the insurer cover a purely cosmetic surgery? This lack of coverage has made doctors and parents in favor of circumcision all the more mad. It's been more than a decade, but last year, the American Academy of Pediatrics finally decided to review and revise those 1999 recommendations on circumcision. With new studies and new research, the AAP released a new Circumcision Policy Statement on August 27th 2012. And this time, the findings of the AAP task force were radically different. The 2012 AAP Circumcision Policy Statement now recommends routine circumcision for male infants. Citing evidence from physicians, peer-reviewed literature and international statistics, the AAP now says that the benefits of circumcision are clear, and greatly outweigh any potential harms. The task force found that circumcision is beneficial firstly to the child as an infant - circumcision is linked to a lower risk of urinary tract infection in young children, as well as other penile-related complications. Also, the study found that it is better to circumcise a child in the neonatal stage, as the surgical process will be much more complicated (and the healing process much longer) if the surgery needs to be performed later in life.

The new Circumcision Policy Statement includes many examples of how infant circumcision can be important to the future health of a male adult. AAP research found that a circumcised man is 40 to 60 percent less likely to contract HIV; likewise, the lowered chance of tears and abrasions on a foreskin will lead to equally lowed chances of contracting other sexually transmitted infections. Indeed, the World Health Organization already recommends circumcision as a preventative measure in countries with a high rate of HIV. The American Academy of Pediatrics also found studies showing that routine male circumcision can lead to better health for a man's female partner - fewer urinary tract infections, and fewer STIs. The task force even found that male circumcision may help prevent cancer; seeing as circumcised men are slightly less likely to pass the Human Papillomavirus (HPV) on to their partner, and HPV can sometimes lead to cervical cancer in women. With all of these benefits, however, some people are still firmly opposed to circumcision. In fact, one could say that the anti-circumcision movement in the United States is even growing, what with multiple areas in California recently attempting to get measures onto voting ballots to ban the practice.

Those people against circumcision call attention to the moral inappropriateness of performing surgery upon a child too young to give his consent, and point out that European men are equally as healthy as American men despite the mere 10 percent of circumcised males. Those opposed to circumcision note the studies showing that circumcision can lead to a loss in sensitivity, as well as the fact that better genital hygiene in general reduces sexually transmitted infections just as much as circumcision. The recent revision of recommendations from the AAP does take into account these points, noting that doctors ought to provide informed and balanced information to families, discussing both the benefits and the risks of circumcision.

The AAP report addresses the ethical issue by pointing out that parents and guardians are always allowed to give consent on behalf of their offspring when it comes to medical procedures performed in the best interest of the child. It will be interesting to see if the new Policy Statement has an effect on insurers or the declining rate of circumcision in the United States. From 2000 until 2008, the rate of circumcision in the U.S. has fallen from 61 to 56 percent, perhaps because more and more insurers are denying coverage for the procedure and families simply can't afford it. The AAP, however, points to studies which demonstrate that higher rates of circumcision will lead to lower medical costs in the future.

Researchers from John Hopkins University recently found that falling rates of circumcision could end up costing the United States billions of dollars in health care costs when those men become adults; therefore, it was recommended that insurance companies cover circumcision now to reduce costs later. The last time the American Academy of Pediatrics published recommendations for circumcision, it was thirteen years before those guidelines were amended. If that trend continues, then the recent Circumcision Policy Statement is a good indicator of how physicians and insurers may behave in the coming future. Whether this will lead to a higher rate of neonatal circumcision, better coverage by insurance companies across the country, or perhaps more vehement protests from those opposed to the procedure, remains to be seen.

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